Thoracic but not lumbar epidural anaesthesia increases liver blood flow after major abdominal surgery.
ABSTRACT Epidural blockade in major abdominal surgery bears the potential to increase gastrointestinal perfusion and thus to improve patient outcome. The aim of this study was to assess the differential influence of thoracic and lumbar epidural anaesthesia and analgesia (EAA) on blood lactate levels and central venous oxygen saturation (ScvO2) as parameters of global oxygen supply/demand ratio, as well as on the plasma disappearance rate of indocyanine green (PDR(ICG)), a noninvasive method to evaluate liver perfusion.
We enrolled 17 patients receiving thoracic and 17 patients receiving lumbar EAA in addition to general anaesthesia for major abdominal surgery. Lactate, ScvO2 and PDR(ICG) were measured postoperatively on the ICU. Subsequently, epidural application of local anaesthetics was started with a bolus of bupivacaine 0.25% (thoracic 10 ml, lumbar 12 ml) followed by continuous infusion of bupivacaine (thoracic 8 ml h(-1) 0.175%, lumbar 10 ml h(-1) 0.125%) and fentanyl (2 microg ml(-1)). Central venous pressure was maintained by titrated volume replacement. Lactate, ScvO2 and PDR(ICG) were measured again after 2 h.
In both the groups, the mean arterial pressure and heart rate as well as lactate levels and ScvO2 did not change significantly. Although there was a slight but not significant decrease of PDR(ICG) in patients with lumbar EAA (from 25.9 +/- 7.68 to 23.2 +/- 5.90; NS), thoracic EAA resulted in a significant increase of PDR(ICG) (from 21.3 +/- 5.13 to 24.0 +/- 6.66; P < 0.05) for the group mean, but with substantial variability in individual patients in the lumbar EAA group.
Liver perfusion was increased with thoracic but not lumbar EAA after major abdominal surgery in most patients. PDR(ICG) allows assessment of individual changes of liver blood flow due to therapeutic intervention, for example, EAA.
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ABSTRACT: Measurement of the indocyanine green plasma disappearance rate (ICG-PDR) has been proposed as a clinical tool for the assessment of liver perfusion and function in transplant donors as well as a prognostic marker. In this study, we analyzed the prognostic value of the ICG-PDR in critically ill patients. Retrospective analysis. Operative ICU of a university hospital. Measurements and results: We analyzed 336 critically ill patients (120 female and 216 male; age range, 10 to 89 years; mean +/- SD age, 53 +/- 19 years) who were treated in our ICU between 1996 and 2000. All these patients were hemodynamically monitored by the transpulmonary double indicator (thermo-dye) dilution technique. Each patient received a femoral artery sheath through which a 4F flexible catheter with an integrated thermistor and fiberoptic was advanced into the abdominal aorta. The ICG-PDR was calculated using a computer system. For each measurement, 15 to 17 mL of 2% indocyanine green were injected in a central vein. Statistical analysis using the lowest value of the ICG-PDR in each individual showed that it was significantly lower in nonsurvivors (n = 168) than in survivors (n = 168) [median, 6.4%/min vs 16.5%/min; p < 0.001]. Sensitivity and specificity with respect to survival was analyzed by receiver operating characteristics. The area under the curve (AUC) as a measure of accuracy was 0.815 when using lowest the ICG-PDR in each patient. For ICU admission (data from 178 patients), AUCs were 0.680 for the APACHE (acute physiology and chronic health evaluation) II, 0.755 for the simplified acute physiology score (SAPS) II, and 0.745 for the ICG-PDR. The ICG-PDR as a marker of liver perfusion and function is a good predictor of survival in critically ill patients: mortality increased with lower ICG-PDR values, and nonsurvivors had significantly lower ICG-PDR values than survivors. Sensitivity and specificity of the ICG-PDR on ICU admission with respect to survival was comparable to that of APACHE II and SAPS II scores.Chest 12/2002; 122(5):1715-20. · 5.85 Impact Factor
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ABSTRACT: Surgery is associated with immune alterations, which are the combined result of tissue damage, anesthesia, postoperative pain, and psychological stress. In the present study, we compared the effects of several postoperative pain management techniques on postoperative immune function. Patients hospitalized for abdominal surgery were randomly assigned to one of three postoperative pain management techniques: opiates on demand (intermittent opiate regimen [IOR]), patient-controlled analgesia (PCA), and patient-controlled epidural analgesia (PCEA). Postoperative pain was assessed. Blood samples were collected before and 24, 48, and 72 h after surgery. Production of interleukin (IL)-1beta, IL-2, and IL-6, natural killer cell cytotoxicity, and lymphocyte mitogenic responses were assessed. Patients of the PCEA group exhibited lower pain scores in the first 24 h after surgery compared with patients of the IOR and PCA groups. Mitogenic responses were suppressed in all groups in the first 24 h, returned to preoperative values by 72 h in the PCEA group, but remained suppressed in the PCA group. Production of IL-1beta and IL-6 increased in the IOR and PCA groups, whereas it remained almost unchanged in the PCEA group. Patients receiving an epidural mixture of opiate and local anesthetics (PCEA group) exhibited reduced suppression of lymphocyte proliferation and attenuated proinflammatory cytokine response in the postoperative period.Anesthesia & Analgesia 10/2003; 97(3):822-7. · 3.30 Impact Factor
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ABSTRACT: In critically ill patients, hepatic dysfunction is regarded as a late organ failure associated with poor prognosis. We investigated the incidence and prognostic implications of early hepatic dysfunction (serum bilirubin >2 mg/dL within 48 hrs of admission). Prospective, multicenter cohort study. Thirty-two medical, surgical, and mixed intensive care units. A total of 38,036 adult patients admitted consecutively over a period of 4 yrs. None. Excluding patients with preexisting cirrhosis (n = 691; 1.8%) and acute or acute-on-chronic hepatic failure (n = 108, 0.3%), we identified 4,146 patients (10.9%) with early hepatic dysfunction. These patients had different baseline characteristics, longer median intensive care unit stays (5 vs. 3 days; p < .001) and increased hospital mortality (30.4% vs. 16.4%; p < .001). Hepatic dysfunction was also associated with higher observed-to-expected mortality ratios (1.02 vs. 0.91; p < .001). Multiple logistic regression analysis showed an independent mortality risk of hepatic dysfunction (odds ratio, 1.86; 95% confidence interval, 1.71-2.03; p < .001), which exceeded the impact of all other organ dysfunctions. A case-control study further confirmed these results: Patients with early hepatic dysfunction exhibited significantly increased raw and risk-adjusted mortality compared with control subjects. Our results provide strong evidence that early hepatic dysfunction, occurring in 11% of critically ill patients, presents a specific and independent risk factor for poor prognosis.Critical Care Medicine 04/2007; 35(4):1099-104. · 6.12 Impact Factor